OMB.report

Federal forms, ICRs, and supporting documents

Information Collection

2014009-XXX_Chikungunya_US Service Org Volunteers

IC 212227 under ICR 201504-0920-005 · OMB 0920-1011.

⚠️ Notice: This information collection may be referencing outdated material. More recent filings for OMB 0920-1011 can be found here:

Documents and Forms

Documents and forms in this information collection
Document Name	Document Type
Letter of Invite from Texas.pdf Letter of Invitation	IC Document
2014009-XXX_Chikungunya_Humanitarian Volunteers.docx Request for Approval	IC Document
Appendix 1-- CASE REPORT FORM.pdf Case Report Form	IC Document
Appendix 2 -- BLOOD COLLECTION Consent, Assent.pdf Blood Collection Consent/Assent	IC Document

Information Collection (IC) Details

View Information Collection (IC)

IC Title:

2014009-XXX_Chikungunya_US Service Org Volunteers

Agency IC Tracking Number:

IC Status: Unchanged

Obligation to Respond: Voluntary

CFR Citation: 42 CFR 301 Public Health Service Act

Information Collection Instruments:

table that charts list of instruments
Document Type	Form No.	Form Name	Instrument File	URL	Available Electronically?	Can Be Submitted Electronically?	Electronic Capability

Federal Enterprise Architecture Business Reference Module

Line of Business: Health

Subfunction: Illness Prevention

Privacy Act System of Records

Title: Epidemic Investigation Case Records

FR Citation: 51 FR 42466

Number of Respondents: 294

Number of Respondents for Small Entity: 0

Affected Public: Individuals or Households

Percentage of Respondents Reporting Electronically: 0 %

table that charts list of burden
	Requested	Program Change Due to New Statute	Program Change Due to Agency Discretion	Change Due to Adjustment in Agency Estimate	Change Due to Potential Violation of the PRA	Previously Approved
Annual Number of Responses for this IC	294	0	0	0	0	294
Annual IC Time Burden (Hours)	184	0	0	0	0	184
Annual IC Cost Burden (Dollars)	0	0	0	0	0	0

Documents for IC

table that charts IC Documents
Title	Document	Date Uploaded
Letter of Invitation	Letter of Invite from Texas.pdf	07/03/2014
Request for Approval	2014009-XXX_Chikungunya_Humanitarian Volunteers.docx	07/03/2014
Case Report Form	Appendix 1-- CASE REPORT FORM.pdf	07/03/2014
Blood Collection Consent/Assent	Appendix 2 -- BLOOD COLLECTION Consent, Assent.pdf	07/03/2014

Blank fields in records indicate information that was not collected or not collected electronically prior to July 2006.